Effects of Health Insurance on Health Service Utilization, Economic Burden and Quality of Care among Households with Non-Communicable Diseases in Busia County, Kenya

Abstract

Non-Communicable Diseases (NCDs) are increasingly becoming important causes of illness and premature deaths globally, responsible for up to 41 million deaths annually, 77% of which occur in LMICs. The major NCDs are cardio-vascular diseases, diabetes, chronic respiratory diseases and cancers. In Kenya they account for more than 50% of all hospital admissions and 39% of hospital deaths. NCDs chronic nature and often late diagnosis after complications have set in, coupled with health system challenges at primary levels of care force households to incur catastrophic health expenditure (CHE) at tertiary and private hospitals. NCDs thus deepen inequality and are the major drivers of unending poverty. Global leaders resolved to address the devastating consequences of NCDs as a developmental challenge under the 2030 Sustainable Development Goals. Kenya committed to achieve universal Health Coverage (UHC) using a primary healthcare approach and NHIF as an enabler. There is however insufficient evidence whether health insurance improves utilization of healthcare services, quality of care and financial protection especially among households of people living with NCDs. This study sought to examine the effects of health insurance on health service utilization, economic burden and quality of care among households with NCDs in Busia County. Specifically, the study examined the effect of HI on; outpatient health service utilization, inpatient health service utilization, financial risk protection and level of satisfaction with quality of care among households of people with NCDs. A quasi-experimental research design (pretest and posttest) was conducted among insured and non-insured (comparison group) households who met eligibility criteria, involving a total representative sample of 350 households. Lists created during registration of beneficiaries were used to create sampling frames. Random sampling was done to select participating households in each group. Every insured household included in the study was matched to a non-insured household of similar baseline characteristics based on calculated propensity scores. Trained interviewers conducted pretest and posttest interviews at an interval of one year among household heads. Ethical approval was obtained from the Moi University Institutional Research and Ethics Committee. Utilization of outpatient and inpatient NCDs care was higher for insured households compared to uninsured. Utilization of outpatient care improved by 1.24 (95% CI= 1.048-1.474), times more among insured households, (p=0.012) while that of inpatient care improved by 1.26 (95% CI = 0.965 -1.634) times more, (p=0.004) among insured households. Households without insurance cover spent a higher proportion of their total income (23%) on NCDs care compared to households with cover (11.7%). The Adjusted mean for out-of-pocket expenditure among intervention group households was KES. 8, 657.37 (95% CI 7, 061.6 - 10, 253.1) while that for comparison group was KES. 16, 851.20 (95% CI 15, 255.4 - 18, 445.0), p value = 0.000. Although the proportion of un-insured households that incurred CHE was higher than that of insured households, the incidence of incurring CHE was not different (χ^2 = 33.89, df =1, p = 0.061). Insured households reported a higher level of overall satisfaction with adjusted mean gap score of -0.522 (SE 0.013), 95% CI (-0.547 to -0.496) than uninsured -0.588 (SE 0.013), 95% CI (-0.613 to -0.563), p value = 0.062. In conclusion, the study found evidence that health insurance has a positive effect on outpatient health service utilization. It also found evidence that health insurance has a positive effect on inpatient health service utilization. The study noted that health insurance has no significant effect on the economic burden among households and that health insurance has no significant effect on the level of satisfaction with quality of care. The study recommends that the Ministry of Health expand the program to enable more people with NCDs utilize outpatient and inpatient care. NHIF be further reformed to remove capitation limits and upfront payments for NCDs. County governments to ring fence funds for improvement of primary level facilities, train more staff on NCDs care to match the rising demand, and mentor workers in key areas of quality care.